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A summary of the Massachusetts health reform experience

June 27, 2011 at 6:00 am

Austin Frakt

Via NBER, Jon Gruber has published a paper today that summarizes the Massachusetts experience under health reform and includes projections for the ACA. Let’s start with the former. I may come back to the ACA projections later.

Gruber describes eleven results from the Massachusetts health reform law, all supported with citations and evidence. His conclusions:

There has been a dramatic expansion of health insurance, reducing the uninsurance rate by 60-70%.

No change in wait times for general and internal medicine practitioners have been observed.

The share of the population with a usual source of care, receiving preventative care, and receiving dental care all rose.

The rate of utilization of emergency care fell modestly.

There has been a 40% decline in uncompensated care.

The proportion of the population with employer-sponsored health insurance increased by 0.6%.

The rate of employer offers of coverage grew from 70% to 76%.

Mandate compliance has been very high: 98% compliance in reporting via tax filings of obtaining coverage or paying penalties.

The administrative costs of health reform have been low. Overall implementation costs have been close to expectations.

Premiums have fallen dramatically in the non-group market.

Though group premiums have risen, they have not increased faster than one would expect from increases in other states in the region.

Those familiar with the literature on this will be able to cite results that seem to counter some of the above. In the paper, Gruber himself has done that, but also explained why some of that work is misleading or imprecise.

What happened to the total health care cost under MA health care reform? With more potential patients into the system, I’d imagine the total cost is up.
If that’s the case, then why the premiums did not go up more? Could it be because the insurance companies have not factored it in?

The point on seeing no change in wait times for general an internal medicine practitioners is missing the story in an important way.

The Mass Medical Society has discussed their PCP shortage in earlier reports, and yesterday the NY Times discussed access to care issues (http://www.nytimes.com/2011/06/27/health/policy/27docs.html?pagewanted=2&_r=2&ref=health), citing Mass Med’s finding that “53 percent of family physicians and 51 percent of internal medicine physicians were not accepting new patients. When new patients could get appointments, they faced long waits, averaging 36 days to see family doctors and 48 days for internists.”

What Gruber’s paper doesn’t detail is that, while the PCP shortage may not have worsened in MA as an effect of reform, it does not seem to have been good in the first place. Maybe he didn’t want to get into the weeds that much, but it’s an important point, given that MA has a generally high supply of PCP’s compared to other states and had a baseline lower rate of uninsurance. The PCP shortage is an issue that deserves more consideration and planning on the part of policymakers and other stakeholders, particularly in states or regions that currently have poor access and a lower supply of PCPs.

Thank you for your comment Tracy, but I think that the point you’re sidestepping IS actually quite interesting.

You’re simply saying that the state of access to Primary Care was, and continues to be, poor. But why didn’t it CHANGE? Millions of new patients and the situations continues to be admittedly poor, but relatively the same?

Bulldog, one of my colleagues just pulled some information on this, and she found that: “Regarding the NBER claim, it seems irrelevant to me that wait times stayed stable between 2007 and 2011, since I think what would matter is the jump between 2006 and 2007. In 2005, the Mass Med Society (MMS) did not report a shortage of PCPs; in 2006 and 2007, they described it as severe (family practice) and critical (internal medicine), and in 2008 and onward, both IM and FM have been ‘critical.’ One thing that seems to be progressively decreasing is the proportion of PCPs accepting new patients.” So it looks like it did change, for the worse, post-reform.

I think we may have to take Mass MS’s new patient survey with a grain of salt. Do we know how accurate it is? Has it been confirmed by other survey?

What kind of doctors will not want to accept new patients? Even in a mature or saturated practice, patients regularly die/move/or change insurances and will need to be replaced by new patients in order to keep busy. Doctors who no longer accept new patients typically are on their way out, waiting to retire.

I am also skeptical about the wait time survey result. It may depends on how the question was asked. If the potential new patient simply asks for an appointment for a “complete physical” or to “establish” as a new patient, it may take a while. But if the patient tells the office that he/she has a genuine problem and needs to be seen soon, I’d think most offices can “squeeze” one or two patients in with no problem.

The MMS survey has been conducted repeatedly over multiple years and has reliably documented shortages in recent years. I am not aware of a similar survey of the same population but the survey is very carefully and professionally done.

The MMS analysis documents that the problem is particularly acute in Western Mass and Southeastern Mass where many PCPs (especially those with a reputation for being good) have long waiting lists for new patients). These are not doctors ready to retire, they are doctors who have more patients than they can service and who have great difficulty recruiting doctors to add capacity to their practice.

Anecdotally, I can attest that when I moved to Western Mass in 2005, I had a very hard time finding a decent PCP who was prepared to offer me an appointment less than 9-12 months out. For the record, I am a reasonably healthy, employed, and pretty well insured (both before and since the reform).

Access to PCPs remains a major problem in Massachusetts, but it is no longer because of the lack of insurance coverage….

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